Treatment results of carotid endarterectomy and carotid artery stenting for patients with radiation-induced carotid stenosis

Purpose@#Exposure to ionizing radiation over the head and neck accelerates atherosclerotic changes in the carotid arteries. Owing to the characteristics of radiation-induced carotid stenosis (RICS), the results regarding the optimal revascularization method for RICS vary. This study compared treatment outcomes between carotid endarterectomy (CEA) and carotid artery stenting (CAS) in RICS. @*Methods@#This was a single-center retrospective review of consecutive patients who underwent CEA or CAS for carotid stenosis. RICS was defined as carotid stenosis (>50%) with the prior neck irradiation for cancer treatment on either side.For the analyses, demographics, comorbid conditions, carotid lesion characteristics based on imaging studies, surgical complications, neurologic outcomes, and mortality during the follow-up period were reviewed. To compare CEA and CAS results in RICS, a 1:1 propensity score matching was applied. @*Results@#Between November 1994 and June 2021, 43 patients with RICS and 2,407 patients with non-RICS underwent carotid revascularization with CEA or CAS. RICS had fewer atherosclerotic risk factors and more frequent severe carotid stenosis and contralateral carotid occlusions than non-RICS. CAS was more commonly performed than CEA (22.9% vs.77.1%) for RICS due to more frequent unfavorable carotid anatomy (0 vs. 16.2%). Procedure-related complications were more common in the CEA than in the CAS. However, there was no significant difference in neurologic outcomes and restenosis rates between CEA and CAS in RICS. @*Conclusion@#Considering its lesion characteristics and cumulative incidence, RICS requires more attention than non-RICS.Although CAS has broader indications for RICS, CEA has shown acceptable results if selectively performed.

Repeated Pseudoaneurysm after Endovascular Repair of Popliteal Aneurysm due to Graft Disintegration and Fabric Tear

Endovascular repair of popliteal artery aneurysms (PAA) using a stent graft is suitable for patients with favorable anatomy. In the domestic situation where Gore Medical withdrew, we report two cases of unusual complications of pseudoaneurysm after endovascular repair of PAA. A 44-year-old male with a history of bypass surgery for a PAA presented with recurrent vein graft pseudoaneurysm. Endovascular treatment using a domestic stent graft was performed. However, pseudoaneurysm developed due to the graft fabric tear 1 month later, requiring surgical removal. In another case, an 84-year-old female presented with acute limb ischemia related to PAA. Endovascular aneurysm repair with the same domestic stent graft was performed. However, stent graft failure occurred 2 years later and the patient underwent open surgical repair. There was a graft fabric disintegration. When proper endovascular device is not available, open surgical treatment is the best option for treating PAA.

Outcomes after Elective Open Abdominal Aortic Aneurysm Repair in Octogenarians Compared to Younger Patients in Korea

Background@#Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality. @*Methods@#All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair. @*Results@#Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P= 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192–224.052; P= 0.037) and 1-year (OR, 8.236; CI, 2.301–29.477; P= 0.001) mortality in all patients. @*Conclusion@#Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality.

Factors associated with long-term graft patency after lower extremity arterial bypasses

Purpose@#This study was conducted to determine factors associated with long-term graft patency after lower extremity arterial bypass (LEAB). @*Methods@#Database of LEABs for patients with chronic arterial occlusive disease (CAOD) at a single institution was retrospectively reviewed. To determine the factors we compared demographic, clinical, and procedural variables between 2 patient groups; group I (graft patency < 2 years) and group II (graft patency ≥ 5 years after LEAB) using univariable and multivariable analyses. @*Results@#Among 957 LEABs, 259 limbs (group I, 125 limbs and group II, 134 limbs) in 213 patients were included for the analysis. On a univariable analysis, younger age (69 years vs. 66 years, P = 0.024), hypertension (60.8% vs. 74.6%, P = 0.017), claudication (51.2% vs. 70.9%, P = 0.001), absence of prior intervention (50.4% vs. 73.9%, P < 0.001), common femoral artery based bypass (57.6% vs. 70.1%, P = 0.035), above-the knee bypass (36.8% vs. 64.2%, P < 0.001), postoperative graft salvage procedure (3.2% vs. 14.8%, P = 0.001), and statin use (75.2% vs. 88.8, P = 0.004) were associated with long-term patency. On a multivariate analysis hypertension (odds ratio [OR], 1.91; P = 0.038), claudication (OR, 2.08; P = 0.032), no prior intervention (OR, 2.48; P = 0.001), vein graft (OR, 4.36; P = 0.001), above-the knee bypass (OR, 4.68; P < 0.001), and graft salvage procedures (OR, 7.70; P < 0.001) were identified as independent factors. @*Conclusion@#These factors can be considered in decision making before treatment of patients with CAOD.

Differential Diagnosis and Treatment Outcomes of Tumors at the Carotid Bifurcation

Purpose@#Primary tumor at the carotid bifurcation is uncommon, which includes paraganglioma, schwannoma, and lymphoma. Due to their rarity, characteristics of these tumors and problems related to their surgical treatment have not been well known. We tried to elucidate different clinical characteristics and surgical complications of these tumors. @*Materials and Methods@#We retrospectively reviewed 21 patients with carotid bifurcation tumor from the Vascular Surgery division of a Korean tertiary institution from 1995 to 2018. We investigated patients’ demographics and clinical features, image characteristics, treatment details, and surgical outcomes. @*Results@#During the period from January 1995 to January 2018, we experienced surgical resections of 21 carotid bifurcation tumors which included 16 (76.2%) paragangliomas and 5 (23.8%) schwannomas. The most common clinical feature was a non-tender cervical mass. According to Shamblin classification, paragangliomas were classified into class II in 68.8% and class III in 25.0%. On the preoperative computed tomography images, all the paragangliomas showed characteristic splaying of the carotid bifurcation and hypervascularity of the tumors. On the contrary, all the schwannomas showed hypovascularity and splaying sign in 60%.Surgical complications related to cervical nerve injury developed in 50% and 60% of patients with Shamblin class III paraganglioma and schwannoma, respectively.During the mean follow-up period of 25 months (range, 1 to 163 months), distant metastases developed in 2 (12.5%) of paraganglioma patients. @*Conclusion@#Neurologic complications were more common after surgical resection of Shamblin class III paraganglioma and schwannoma. For patients with paraganglioma, postoperative periodic follow-up examination is advised to detect distant metastasis.

Inconsistent Use of Terminology and Different Treatment Outcomes of Venous Adventitial Cystic Disease: A Proposal for Reporting Standards

Adventitial cystic disease (ACD) is a very rare condition characterized by the accumulation of a cyst filled with gelatinous substance in the adventitia of a vessel adjacent to the joint area. The cyst usually compresses the vessel lumen, causing claudication or leg swelling. The disease usually affects the popliteal artery. However, several cases of venous ACDs particularly in the common femoral or external iliac vein have been reported. The definition, diagnosis, and optimal treatment of ACD remain controversial because of its rarity and the inconsistent use of terminology. The heterogeneity of the reported cases is more prominent in venous ACD. Herein, the accurate terminology of cysts correlated to the joint (synovial cyst, ganglion cyst, and adventitial cyst) and the pathogenesis, anatomy, and optimal therapy of venous ACD are discussed in detail to establish reporting standards for future studies.

A survey investigating the current situation of the international visiting scholar program at the department of surgery in Korea

Purpose@#The number of international visiting scholars has been on the increase in Korea and we aim to investigate the program’s current situation. @*Methods@#This cross-sectional study is based on an online survey questionnaire responded by international visiting scholars in surgical departments of 8 Korean hospitals between 2014 and 2018 about their experiences and satisfaction with the visiting scholar program. @*Results@#A total of 1,496 international scholars from 80 countries visited various surgical departments in 8 Korean hospitals between 2014 and 2018. The numbers have been on the increase over the years. Out of 355 visiting scholars in 2018, 71 replied to the online survey, of whom 52 were male and 19 female, and mostly in their 30s and 40s. Information about the program was accessed mostly through friends or colleagues (42.3%) and international conferences (36.6%). The commonest funding source was private (35.2%) and more than half stayed for less than 3 months. The visiting scholar’s main roles were mostly observation or participation in surgery and clinical research. All but 1 were satisfied with the program (98.6%) and would recommend it to friends and colleagues, although the language barrier was identified as an inconvenience. Those aged 20–39 years with governmental or institutional funding were associated with stays of more than 1 year. @*Conclusion@#The number of international visiting scholars at surgical departments in Korean hospitals has been on the increase with high satisfaction levels. Improvements need to be made on funding sources and lengthening visiting period to maximize the benefits of the program.

Strategy to avoid open surgical conversion after endovascular aortic aneurysm repair for patients with infrarenal abdominal aortic aneurysm

Purpose@#Open surgical conversion (OSC) is the last treatment option for patients with endovascular aneurysm repair (EVAR) failure. We investigated the underlying causes of EVAR failure requiring OSC and attempted to determine strategies to avoid OSC after EVAR. @*Methods@#We retrospectively reviewed the database of patients who underwent OSC after EVAR from 2005 to 2018 in a single institution. Twenty-six OSCs were performed in 24 patients (median age, 74.5 years; 79.2% of males) who had undergone standard EVAR. We investigated pre-, intra-, and postoperative computed tomography or angiographic images and outcomes of the OSCs. @*Results@#Two main indications for OSC were persistent endoleak (50.0%) and endograft infection (EI) (38.5%). All 13 patients who underwent OSC due to endoleaks received EVAR outside of indications for use. Among 10 patients who underwent OSC due to EI, we found overlooked infection sources in 7 (70.0%) at the time of EVAR or during the surveillance period.OSC was performed at a median of 31.8 months (interquartile range, 9.4–69.8) after EVAR as an emergency (15.4%) or elective (84.6%) surgery. Aortic endograft was removed in 84.6% of cases (totally, 57.7%; partially, 26.9%), whereas it was preserved in 4 cases (15.4%). After 26 OSCs, 2 early deaths (7.7%) and 2 aortoenteric fistulae (7.7%) developed as major complications. @*Conclusion@#OSC after EVAR was associated with relatively higher perioperative morbidity and mortality. To avoid OSC after EVAR, we recommend careful assessment of coexisting infection sources and avoidance of EVAR for patients with especially unfavorable anatomy for EVAR, particularly the in proximal neck.

Surgical Strategy to Reduce the Recurrence of Adventitial Cystic Disease after Treatment

PURPOSE: Adventitial cystic disease (ACD) is a rare condition that causes intermittent claudication and non-atherosclerotic disease without cardiovascular risk factors. The etiology and optimal treatment of ACD remain controversial. The purpose of this study was to analyze surgical treatment results for ACD and to elucidate optimal treatment options.MATERIALS AND METHODS: We retrospectively reviewed 30 patients with ACD who underwent surgery from 2006 to 2018. Twenty-two patients had arterial ACD, six had venous ACD, and two had combined venous and arterial ACD. We reviewed demographic and clinical characteristics, treatment details, and procedure outcomes.RESULTS: Recurrence occurred in 6 cases either after cyst excision alone (4/17) or patch angioplasty (2/2). There was no recurrence after vessel excision with interposition grafting (0/7). Therefore, vessel excision was a statistically significant factor in recurrence prevention (P=0.026). Among the six recurrences, joint connections of the cystic lesions were found in four of the six (66.7%).CONCLUSION: As a curative surgery for ACD, vessel excision with interposition grafting is a better strategy to prevent recurrence than simple cyst excision alone.

Long Term Outcomes of Femorofemoral Crossover Bypass Grafts

PURPOSE: Femorofemoral crossover bypass (FCB) is a good procedure for patients with unilateral iliac artery disease. There are many articles about the results of FCB, but most of them were limited to 5 years follow-up. The purpose of our study was to analysis the results of FCB with a 10-year follow-up period. MATERIALS AND METHODS: Between January 1995 and December 2010, 133 patients were operated in Samsung Medical Center (median follow-up: 58.8 months). We retrospectively analysed patient characteristics, the preoperative treatment, the operative procedure, and material used. RESULTS: The indications for FCB were claudication in 110 and critical limb ischemia in 23 patients. Three patients were died due to myocardiac infarction, intracranial hemorrhage, and acute respiratory failure within 30 days after surgery. The one-year primary and secondary patency rates were 89% and 97%, the 5-year primary and secondary patency rates were 70% and 85%, and the 10-year primary and secondary patency rates were 31% and 67%. The 5-year and 10-year limb salvage rates were 97% and 95%, respectively. CONCLUSION: Our long term analysis suggests that FCB might be a valuable alternative treatment modality in patients with unilateral iliac artery disease.

Usefulness of intraopertive ultrasonography during directional atherectomy using SilverHawk/TurboHawk system

PURPOSE: Directional atherectomy (DA) was introduced for the management of infrainguinal arterial stenosis or occlusive lesions. The procedure success rate in the DEFINITIVE LE study was determined using radiologic imaging. The aim of our study was to determine the usefulness of intraoperative ultrasonography (USG) during DA for evaluating the early results of this procedure. METHODS: Patients who underwent DA from January to December 2014 were reviewed retrospectively. Twenty lesions from 14 patients with femoral artery stenosis (>70% stenosis) with short segment occlusive lesions (<2 cm in length) were treated. Among 20 lesions, 3 were treated with the TurboHawk system with a protective device due to lesion calcification. The percentage of stenosis during and after DA was determined with USG. RESULTS: Median follow-up was 5.1 months, and the procedural success rate (<30% stenosis at the end of the procedure) was 100% on angiography, but only 30% on intraoperative USG. On USG, median residual stenosis was 40% (range, 28%–42%) at the end of DA, 40% (range, 30%–55%) at 1 month, 55% (range, 35%–85%) at 6 months, and 64% (range, 60%–100%) at 1 year. There was one dissection, but no cases of perforation, pseudoaneurysm, or thrombosis. Primary patency, which was defined as a peak systolic velocity ratio ≤3.5 with no reintervention at 6 months, was found in 18 lesions (90%), and 11 of 14 patients (78.6%) were free of ischemic symptoms such as claudication at 6 months. CONCLUSION: Our results demonstrated that DA with intraoperative USG is an effective treatment option for short segment occlusive lesions of the femoral artery.

Aorto-carotid bypass in patients with Takayasu arteritis

PURPOSE: Takayasu arteritis is an indication for bypass surgery when this condition results in severe cerebrovascular ischemia due to occlusion of the carotid arteries. We reviewed the patients with Takayasu arteritis who received aorto-carotid bypass due to cerebrovascular ischemia. METHODS: A retrospective review was performed on 19 patients with Takayasu arteritis who underwent aorto-carotid bypass from March 2002 to April 2015. RESULTS: All patients were female and the mean of their age was 40.6 ± 15.3 years. Eleven patients (57.9%) underwent aorto-uni-carotid bypass and 8 patients (42.1%) underwent aorto-bi-carotid bypass. Five patients (26.3%) whose postoperative blood pressure was not controlled suffered an intracranial hemorrhage within 8 days after bypass surgery. Of the patients with an intracranial hemorrhage, 2 patients (10.5%) expired on 26 days and 7 years after surgery, and 3 patients (15.8%) resolved spontaneously. One patient (5.3%) expired due to an intracranial infarction 9 years after bypass surgery. The intracranial ischemic symptoms resolved after bypass surgery in all of the surviving patients. None of the patients experienced anastomosis site complication postoperatively. CONCLUSION: Aorto-carotid bypass is effective for treating Takayasu arteritis with cerebrovascular ischemia, and the results suggest that postoperative blood pressure should be strictly managed to prevent intracranial hemorrhage.

Frequency of concomitant ischemic heart disease and risk factor analysis for an early postoperative myocardial infarction after elective abdominal aortic aneurysm repair

PURPOSE: We aimed to see the frequency of concomitant ischemic heart disease (IHD) in Korean patients with abdominal aortic aneurysm (AAA) and to determine risk factors for an early postoperative acute myocardial infarction (PAMI) after elective open or endovascular AAA repair. METHODS: We retrospectively reviewed a database of patients who underwent elective AAA repair over the past 11 years. Patients were classified into 3 groups: control group; group I, medical IHD treatment; group II, invasive IHD treatment. Rates of PAMI and mortality at 30 days were compiled and compared between groups according to the type of AAA repair. RESULTS: Six hundred two elective repairs of infrarenal or juxtarenal AAAs were enrolled in this study. The patients were classified into control group (n = 398, 66.1%), group I (n = 73, 12.1%) and group II (n = 131, 21.8%). PAMI developed more frequently after open surgical repair (OSR) than after endovascular aneurysm repair (EVAR) (5.4% vs. 1.3%, P = 0.012). In OSR patients (n = 373), PAMI developed 2.1% in control group, 18.0% in group I and 7.1% in group II (P < 0.001). In EVAR group (n = 229), PAMI developed 0.6% in control group, 4.3% in group I and 2.2% in group II (P = 0.211). On the multivariable analysis of risk factors of PAMI, PAMI developed more frequently in patients with positive functional stress test. CONCLUSION: The prevalence of concomitant IHD was 34% in Korean AAA patients. The risk of PAMI was significantly higher after OSR compared to EVAR and in patients with IHD compared to control group. Though we found some risk factors for PAMI, these were not applied to postoperative mortality rate.

Lower Extremity Arterial Bypass with Arm Vein Conduits and Literature Review

PURPOSE: The superiority of autogenous vein conduits is well known in lower extremity arterial bypass (LEAB). Among various alternative conduits for LEAB, long-term results of arm vein grafts were investigated in this study. MATERIALS AND METHODS: We retrospectively reviewed clinical characteristics of 28 patients who underwent infrainguinal LEAB with autogenous arm vein grafts at a single institute between January 2003 and December 2015. All procedures were performed in the absence of adequate saphenous veins. Graft patency was determined by periodic examinations with duplex ultrasonography. RESULTS: Autologous arm vein grafts were implanted for 28 patients (mean age, 60.4±16.8 years; range, 20–82 years; male, 92.9%; atherosclerosis, 19 [67.9%]; and non-atherosclerotic disease 9 [32.1%] including 5 patients with Buerger’s disease). Source of arm vein were basilic 13 (46.4%), cephalic 4 (14.3%) and composition graft with other veins in 11 (39.3%) cases. The level of distal anastomosis was distributed as popliteal in 5 (17.9%), tibio-peroneal in 21 (75.0%) and inframalleolar artery in 2 (7.1%) cases. Mean duration of follow-up was 41.5±46.9 months (range, 1–138 months). Cumulative primary patency rates at 1, 3, and 5 years were 66.5%, 60.9% and 60.9%, respectively. Assisted-primary patency rates at 1, 3 and 5 years were 66.5%, 66.5% and 66.5%, respectively. Secondary patency rates at 1, 3 and 5 years were 70.8%, 70.8% and 70.8%, respectively. There was one limb amputation during the follow-up period. CONCLUSION: Arm veins are a useful alternative conduit when great saphenous veins are not available during LEAB.

Effect of imatinib mesylate and rapamycin on the preformed intimal hyperplasia in rat carotid injury model

PURPOSE: Intimal hyperplasia (IH) is the main cause of restenosis or occlusion after vascular procedures. Imatinib mesylate and rapamycin are known to prevent IH. The purpose of this study was to evaluate the effect of these drugs on the regression of preformed IH in rat carotid injury model. METHODS: IH was established in rat carotid arteries using a balloon catheter. The drug effects were assessed in vitro on proliferation, migration, and apoptosis of vascular smooth muscle cells (VSMC) in the neointima. And in vivo studies were carried out in 4 groups: imatinib, rapamycin, combined, and no medication. After 2-week oral medication, morphometric analysis evaluated the number and density of neointimal cells, intima-to-media (I/M) ratio and cross-sectional area. Cell proliferation, apoptosis, and collagen changes were also investigated by immunohistochemical staining (IHCS). RESULTS: Imatinib and rapamycin significantly inhibited VSMC proliferation and migration, and promoted apoptosis in vitro. In morphometric analysis, the number and density of neointimal cells decreased significantly in all medication groups compared with control group (P < 0.01). However, there was no significant difference in neointimal cross-sectional area and I/M ratio among groups. In IHCS, imatinib and rapamycin inhibited neointimal cell proliferation significantly. However, there was no significant change in cell apoptosis and collagen composition. CONCLUSION: Combined treatment of with imatinib and rapamycin induced reduction of cell mass in preformed intimal hyperplasia, but failed to induce regression of intimal mass in this short-term medication study. Further studies will be needed with additional strategies of inducing lysis of the extracellular matrix.

Comparison of long-term results of above-the-knee femoro-popliteal bypass with autogenous vein and polytetrafluoroethylene grafts

PURPOSE: To analyze the long-term results of above-the-knee femoro-popliteal bypass (ATKFPB) with vein grafts compared with polytetrafluoroethylene (PTFE) grafts. METHODS: A database of patients with chronic atherosclerotic occlusive disease who underwent ATKFPB was retrospectively reviewed. Characteristics of patient and arterial lesion, and follow-up results were compared between vein grafts and PTFE grafts. Graft patency was determined by periodic examinations of duplex ultrasonography or CT angiograms. Graft patency and limb salvage rates were calculated using the Kaplan-Meier method. RESULTS: In total, 253 ATKFPBs (107 vein grafts; 146 PTFE grafts; critical limb ischemia, 32%) were performed on 228 patients (mean age, 68.5 years; male, 87.7%). No significant differences were observed between the two groups with respect to demographic characteristics, characteristics of arterial lesions, or distal runoff score. During the mean follow-up period of 41 months (range, 1-122 months), 14.5% patients died, and 94% of all limbs were available for follow-up. The primary patency rates were not significantly different between the two groups at 10 years after treatment (75% vs. 42%, P = 0.330). However, the primary-assisted patency rates (88% vs. 42%, P = 0.003) and secondary patency rates (91% vs. 49%, P = 0.013) were significantly higher in the vein grafts compared with the PTFE grafts. Graft occlusion developed more often in the PTFE grafts (5.6% vs. 20.5%, P = 0.001). When graft occlusion occurred, acute limb ischemia was significantly more frequent in the PTFE grafts than in the vein grafts (0% vs. 53%, P = 0.027). CONCLUSION: After ATKFPB, autologous vein grafts showed significantly better long-term results compared with PTFE grafts.

Follow-up results of acute portal and splenic vein thrombosis with or without anticoagulation therapy after hepatobiliary and pancreatic surgery

PURPOSE: Acute portal and splenic vein thrombosis (APSVT) after hepatobiliary and pancreatic (HBP) surgery is a rare but serious complication and a treatment strategy has not been well established. To assess the safety and efficacy of anticoagulation therapy for treating APSVT after HBP surgery. METHODS: We performed a retrospective case-control study of 82 patients who were diagnosed with APSVT within 4 weeks after HBP surgery from October 2002 to November 2012 at a single institute. We assigned patients to the anticoagulation group (n = 32) or nonanticoagulation group (n = 50) and compared patient characteristics, complications, and the recanalization rate of APSVT between these two groups. RESULTS: APSVT was diagnosed a mean of 8.6 +/- 4.8 days after HBP surgery. Patients' characteristics were not significantly different between the two groups. There were no bleeding complications related to anticoagulation therapy. The 1-year cumulative recanalization rate of anticoagulation group and nonanticoagulation group were 71.4% and 34.1%, respectively, which is statistically significant (log-rank test, P = 0.0001). In Cox regression model for multivariate analysis, independent factors associated with the recanalization rate of APSVT after HBP surgery were anticoagulation therapy (P = 0.003; hazard ration [HR], 2.364; 95% confidence interval [CI], 1.341-4.168), the absence of a vein reconstruction procedure (P = 0.027; HR, 2.557; 95% CI, 1.111-5.885), and operation type (liver resection rather than pancreatic resection; P = 0.005, HR, 2.350; 95% CI, 1.286-4.296). CONCLUSION: Anticoagulation therapy appears to be a safe and effective treatment for patients with APSVT after HBP surgery. Further prospective studies of larger patient populations are necessary to confirm our findings.

Different Responses of Neointimal Cells to Imatinib Mesylate and Rapamycin Compared with Normal Vascular Smooth Muscle Cells

PURPOSE: This study was designed to investigate whether vascular smooth muscle cells (VSMC) from the neointima showed any different response to antiproliferative agents, such as rapamycin or imatinib mesylate, compared to VSMCs from normal artery. MATERIALS AND METHODS: Intimal hyperplasia was made by carotid balloon in jury in male rats. Neointimal cells at 4 weeks after injury and normal VSMCs were extracted by enzymatic isolation method and cultured. Cell viability and proliferation were tested in VSMCs from injured left carotid artery and uninjured right carotid artery. Tests were repeated with rapamycin, imatinib mesylate or both in various concentrations. RESULTS: Rapamycin decreased cell viability only at a high concentration of 10(-5) M in uninjured VSMCs. Combined drugs decreased cell viability at a lower concentration of 10(-7) M in uninjured VSMCs, and at a higher concentration of 10(-5) M in neointimal cells. Overall, rapamycin showed cytocidal effects at a high concentration of 10(-5) M, whereas imatinib did not. Cell proliferation of neointima was significantly decreased along with the drug concentration. Cell proliferation of uninjured VSMCs was significantly decreased at higher drug concentrations. Combined drug therapy showed synergistic effects. Overall, neointimal cells are more susceptible to the antiproliferative effects of the drugs. CONCLUSION: Neointimal cells from the injured carotid artery are more susceptible to the antiproliferative effect of imatinib and rapamycin. Both drugs can be a used for the prevention of intimal hyperplasia, which could be investigated through further in vivo studies.

Results of Open Surgical Repair of Chronic Juxtarenal Aortic Occlusion

PURPOSE: The aim of study was to review the results of open surgical repair (OSR) of chronic juxtarenal aortic occlusion (JRAO). MATERIALS AND METHODS: We retrospectively reviewed the results of OSR performed in 47 patients (male, 92%; mean age, 59.9+/-9.3 years [range, 44-79]) with chronic JRAO during the past 21 years. In order to reduce intraoperative renal ischemic time (RIT), we excised a portion of the occluded segment of the infrarenal aorta without proximal aortic clamping. We then performed suprarenal aortic clamping with both renal arteries clamped, removed the proximal aortic thrombus cap, confirmed both renal artery orifices, and moved the suprarenal aortic clamp to the infrarenal aorta to allow renal perfusion and standard aortoiliac reconstruction. We investigated early (<30 days) postoperative surgical morbidity (particularly renal function), operative mortality, and longterm patient survival. We conducted risk factor analysis for postoperative renal insufficiency. RESULTS: The mean intraoperative RIT was 10.7+/-5.5 minutes (range, 3-25), including 6 patients who underwent concomitant pararenal aortic thromboendarterectomy. Postoperatively, five (11%) patients had transient renal insufficiency, one had pneumonia, and one patient had an acute myocardial infarction. However, there was no operative mortality or newly developed dialysis-dependent renal failure. Postoperative follow up was available in 36 (77%) patients for a mean period of 6.3 years (range, 1 month-17 years). Kaplan Meier calculations of patient survival at 5 and 10 years after surgery were 91.2% and 83.6%, respectively. CONCLUSION: We have experienced short RIT, acceptable early postoperative results and long-term survival after OSR of chronic JRAO.

Clinical Characteristics of Acute Arterial Thromboembolism of Upper Extremity / 대한혈관외과학회지

PURPOSE: To evaluate the clinical characteristics and treatment outcomes of acute upper extremity thromboembolism. METHODS: From April 1997 to July 2012, nineteen patients (10 males, mean age 69.7 years) were treated for acute upper extremity thromboembolism. Iatrogenic or traumatic acute thromboembolisms were excluded. We retrospectively reviewed patient demographics, clinical characteristics (symptom, risk factor, involved artery, and duration from initial symptom onset to primary treatment) and treatment outcomes. RESULTS: Numbness or tingling sense was the most common symptom in patients (84.2%). Twelve patients (63.1%) had cardiac arrhythmia, of which 9 patients had atrial fibrillation (47.3%). Floating thrombus was detected on transesophageal echocardiography in 6 patients. Fourteen patients (73.7%) were treated within 24 hours from the symptom onset. Most thromboembolism was located in the brachial artery bifurcation with or without proximal or distal extension. Fogarty catheter thromboembolectomy was the primary treatment in 17 patients (89.5%), of whom 13 patients (72.2%) were operated under local anesthesia. All patients received anticoagulation or antithrombotic therapy after the procedure. Three patients had recurrent thrombosis on duplex scan; however, their symptoms were improved without further intervention. All other patients were symptom-free without recurrence during the mean follow-up of 17.1+/-21.3 months. CONCLUSION: Early diagnosis and Fogarty catheter thromboembolectomy under local anesthesia followed by proper anticoagulation is the most effective and useful treatment in patients with acute upper extremity thromboembolism.